Management of Condom Rupture During Intercourse

Step 1 - Rapid Assessment (First 5 Minutes)

Step 2 - Emergency Contraception

Option A: Levonorgestrel (LNG) - First-line, OTC available

• Dose: Single oral dose of 1.5 mg (preferred over two 0.75 mg doses 12 hours apart - equally effective, simpler)
• Window: Labeled up to 72 hours; some evidence for use up to 120 hours with declining efficacy
• Efficacy: Reduces pregnancy risk by ~89%; best in first 24 hours
• Side effects: Nausea, headache, irregular bleeding (resolves without treatment)
• Mechanism: Delays or inhibits ovulation - does NOT terminate an existing pregnancy
• Important caveat: Efficacy is reduced in women with BMI >30 due to lower drug concentrations

"Efficacy declines linearly with time, but there is efficacy up to 120 hours after intercourse." - Harriet Lane Handbook, 23rd ed.

Option B: Ulipristal Acetate (UPA) - Preferred if BMI >30 or 72-120 hours

• Dose: Single oral dose of 30 mg (Ella; prescription required)
• Window: Up to 120 hours with sustained efficacy
• Advantage over LNG: Significantly more effective when ovulation is imminent; 42% lower odds of pregnancy at 72 hours, 65% lower in first 24 hours
• Note: After taking UPA, wait 5 days before starting hormonal contraception (starting immediately reduces efficacy); CYP3A4 inducers (rifampin, phenytoin, barbiturates) reduce its effectiveness

Option C: Copper IUD - Most effective option

• Efficacy: ~100% when inserted within 5 days; effective up to 7 days
• Advantage: Provides ongoing contraception (up to 10-20 years); best choice if patient desires long-term contraception
• Risk: 1/1000 uterine perforation risk; cramping/irregular bleeding common
• Limitation: Requires provider insertion; upfront cost

Comparative Efficacy Summary

"Nine times as many women choose oral hormonal EC over copper IUD despite evidence of superior efficacy of the copper IUD (risk reduction 99.2% vs 89% and 74%)." - Textbook of Family Medicine, 9e

Step 3 - STI Risk Assessment and Management

Screening (if new/unknown partner or high-risk):

• Swabs: NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae (urethral/cervical)
• Serology: HIV (baseline), Syphilis (RPR/VDRL), Hepatitis B and C
• Wet prep / microscopy if vaginal discharge present

STI Prophylaxis (if high-risk exposure or partner of unknown status):

• Chlamydia/Gonorrhea: Ceftriaxone 500 mg IM + Azithromycin 1 g orally (or doxycycline 100 mg BD x 7 days)
• Arrange follow-up in 2 weeks for STI results

HIV Post-Exposure Prophylaxis (PEP):

• If the partner is HIV-positive or of unknown status in a high-risk setting, refer urgently for PEP - must be started within 72 hours (ideally within 2 hours)

Step 4 - Counseling

1. EC is NOT an abortifacient - It prevents fertilization by delaying ovulation. It has no effect on an already-implanted embryo. Clarify this common misconception.
2. Same-cycle pregnancy still possible - EC is not 100% effective. Advise using barrier contraception for the rest of this cycle.
3. Pregnancy test: If menstruation does not occur within 3 weeks of EC use, perform a urine pregnancy test.
4. Irregular bleeding is expected - Spotting or a shift in the next period is normal and resolves spontaneously.
5. Start reliable long-term contraception: Since this couple was relying solely on condoms:
   • Discuss combined oral contraceptive pills (COCPs), LNG-IUD, Cu-IUD, or subdermal implant
   • Can start COCPs immediately after LNG; wait 5 days if ulipristal was used
   • ACOG recommends IUDs as first-line in sexually active young women (lowest discontinuation rates at 24 months: 23% vs. 57-60% for pills/patch)
6. Correct condom use: Review proper technique - correct size, air bubble removal at tip, use of water-based lubricant, check expiry date.
7. STI screening: Recommend regular STI screening for sexually active young adults regardless of relationship status.

Summary Algorithm

Condom rupture 2 hours ago
        ↓
Urine hCG → negative → Proceed with EC
        ↓
BMI normal, within 72h → LNG 1.5 mg orally STAT
  (or ulipristal 30 mg if BMI >30 or near ovulation)
  (or Cu-IUD if desires long-term contraception)
        ↓
STI risk assessment → screen if indicated
HIV PEP if high-risk exposure within 72 hours
        ↓
Counsel: EC mechanism, follow-up pregnancy test at 3 weeks,
          start reliable contraception, correct condom use

• Rosen's Emergency Medicine, 9e - Emergency Contraception chapter
• Berek & Novak's Gynecology - Emergency Contraception section
• Textbook of Family Medicine, 9e - Emergency Contraception
• CDC U.S. Selected Practice Recommendations for Contraceptive Use, 2024
• Society of Family Planning Clinical Recommendation: Emergency Contraception, 2023 [PMID: 37930357]